Kreziel D. Escobar

MOCK CODE

CASE: Respiratory distress(Disordered Control of breathing)- Respiratory Failure- Ventricular Fibrillation

Scenario:

A 6 years old male came to emergency with trouble breathing, lethargic, increase effort upon breathing, pale skin with history of cough, shortness of breath and fever for 3 days. Known case of Bronchial Asthma and Cerebral Palsy with seizure disorder.

Part 1:

First responder came and assist patient, placed non- rebreathing mask 10 liters /minute.

Resus team arrives: Identification of name and role in the team

Nurse 1: Secure airway-suction secretions

Nurse 2: Procedure- connects to cardiac monitor

-apply pulse oximeter , take weight(broselow),check temperature

Nurse 3: Medication – prepare ventolin and atrovent

Nurse 4:Documentation

Vital signs:

T 39.7/rectal, PR 130/MIN ,peripheral pulse normal, BP 102/50, SPO2: 80%, RR 62/min, sterna retraction, excess secretions, coarse breath sounds

Weight: 18 kg by broselow

Nurse 3: Paracetamol given 270mg per rectal(15mg/kg)

Part 2: Secondary Assessment

Patient is lethargic, weak, with fever, cough, shortness of breath for 3 days , unknown allergies, on medication: phenobarbitone, topamax, Last meal taken per gastrostomy 3 hours ago, vomitted after feeding with acute onset of respiratory distress

Please repeat vital signs:

T 38.2/rectal, HR 120/min, SPO2 92% (Oxygen), BP 90/50, RR 52 with secretions, still labored breathing

Part3

Kreziel: Please insert IV line , get blood works (CBC, U/E, Calcium,Magnesium, VBG, HGT, Blood culture and sensitivity, Drug level

Nurse 2: IV line inserted , blood works taken, HGT- 4.5 mmol/l

Kreziel: Start IV bolus of 0.9 NaCl 360 ml 0ver 30 minutes (20ml/kg)

Maintenance : D50.45NaCl 70ml per hour

Also give ventolin 5mg and atrovent 250 mcg for 3 doses back to back

Please request portable chest xray (Suspected : Aspiration Pnuemonia)

Prepare ceftriaxone 1350mg IV(75mg/kg) max:2 gram, wt:18 kg

Nurse3: Ceftriaxone 1350 m given IV over 30 minutes

Part 4:

Reassessment of the patient

Vitals Signs

T 38C/rectal ,PR 152, BP 103/58, SPO2 70% (oxygen) desaturating , RR 14

Kreziel: Prepare Intubation

Nurse 1: Equipments for intubation prepared

(ET TUBE size: , laryngoscope, stylet, 10 cc syringe , ky jelly)

Nurse 3: Rapid Sequence Intubation Medication prepared

( succynlcholine3.6mg (0.2mg/kg), atropine1.8mg(0.1mg/kg), midazolam1.8 mg(0.1mg/kg)

Doctor: Successfully intubation done

Kreziel: Please rechecked saturation

Nurse 1: Now, saturating 98%

Kreziel: Request portable chest x-ray for confirmation of ET tube

Chest xray technician came and chest xray done: ET tube was in place

Part 5

Suddenly patient deteriorates, HR 52, BP 49/39mmhg, Spo2 95%

NURSE 2: Notice Ventricullar Defibrillation

Doctor: Please start compression and continue bagging

Prepare for defibrillation

NURSE 2: Compression started

Kreziel: turn the knob give 36 joules (2 joules/kg)

Doctor: Clear the patient for defibrillation, I am clear,your clear, everybody clear, oxygen away, shocked delivered.

Nurse2: resume compression

Nurse1: Secured airway( bagging)

Kreziel: Good job Nurse 2 , your doing right in way: push hard ang fast , Nurse 1: securing airway

Nurse2:( 3 cycles of CPR)

Kreziel: 3 MINUTES over , Lets assess the rhythm

Doctor: Still showing Ventricular Fibrillation

Kreziel: Prepare for next defibrillation 140joules (4joules/kg)

Resume Compression

Nurse 4: 3 minutes over

Kreziel: Lets analyze rhythm( Normal sinus rhythm)

Please check pulse

Nurse 2: peripheral pulse is present and matching the monitor

Kreziel : any laboratory available

CBC RESULTS :WBC-6.3, HGB:12 , HCT: 35.9% , MCV:83.4 MCH:27.9 MCHC:334 , RDW: 12.5 %PLATELET:198 neutrophils:41.3% LYMPHOCYTES 48.2% basophils 0.7%

UREA &ELECTROLYTES: RBS: 22.5mmol/l Urea:4.1mmol/l, creatinine 62 umol/l, sodium 132mmol/l,potassium 2.8mmol/l, chloride 95 mmol/l, bicarbonate 27 mmol/l, osmolality 290.3 mosm/kg

VENOUS BLOOD GAS: pH: 7.20, PCO2:38.9, PO2:46, BICARBONATE 20, TOTAL CO2 24.9,OXYGEN SATURATUION 81% , haemoglobin12.9

Kreziel: Please change fluid to D50.45NACl + 30 mmol/liter KCL at 70 ml/hr

Part 6 :TERTIARYASSESSMENT

Afebrile 37C/rectal

PR 128/min

SPO2: 98%( intubated)

Normal sinus rhythm , with IV fluid

Patient is stable .Please call PICU and we will shift the patient.